 Welcome to the 38th meeting of the Health, Social Care and Sport Committee in 2023. I have received no apologies for today's meeting. The first item on our agenda is to decide whether to take items 4 and 5 in private. Our members agree. Agenda item 2 is the fourth oral evidence session as part of the committee's inquiry into healthcare in remote and rural areas. Oes gan y trodduradur ddechrau, drwy gyfio'r seishwn, seintrubodd mwy ychwanedig gyfio'r pryddoedd. Mae'r ddogfais i ddion nhw yng Nghs Highland Prydyn math yn y byd amdano. Jackie Lambert, y rhai coleg yng ng beginning y gyfyrdd cangfeydd yn Mydwis, Gorffian, Nicola Gordon, y polynigr Imbug counsel yng thrym yng nghyrch byd yn Ynny'r Corry Gwedd yn yr ysgolod yng Nghymru,bydd yn sicrhau yng Nghymwr o gyllidebau i'r gwirionedd. Ivan McKee. Thank you very much, convener, and good morning panel who is here and those online. I'd like to focus on the proposed national centre and to get your sense of how you see that to contributing to addressing the challenges that we face in remote and rural healthcare. I might start by opening up by asking what you think the priority should be for the national centre over its first few years. I don't know if anyone is willing to jump in and give a perspective on that. It has warmed up on when you go. Sorry. My perspective is certainly that in the remote and rural areas we struggle because we have a lack of affordable housing. I cover the whole of NHS Highland in a Gaelan Bute, which is a landmass of Belgium. When people come to these areas, I don't think they first understand the rurality in these areas. Therefore, they come back to us saying that they can't afford to pay the rents that are being charged. You can understand in areas like Islay and 36 islands in NHS Highland that we don't have a lot of housing, so they can charge what they like. People can't afford the pay that NHS staff are being paid. We definitely need to encourage people to come to Highland. I'm not just talking about nursing, but about AAHP staff, doctors, junior doctors or whatever. We need affordable housing for staff to be able to come there and bring their families to these areas. What I'm saying is that unless the national centre and other work addresses that issue, the other work that it's doing is going to have limited value. I think that the bottom line is that if you don't have the resources and the resources of the staff, where do you go from there? Absolutely. Michael, I don't know if you get any thoughts on that. I think that the first thing is that it's not a numbers game. It's really easy to focus on just the number of staff we would need, but actually in small teams that you find in rural locations, the difference between one and two people can be absolutely vast in terms of sustainable services. Of course, if you lose a couple of people, then it can destabilise the whole team. More people are likely to say, well, actually, this isn't right for me. For me, the focus has to be about putting remote and rural as a badge of honour, front and centre in terms of what the work of health and social care looks like moving forward. It's a huge privilege to work in these communities. It's a massive opportunity to see a breadth of activity that you simply wouldn't get to see if you're working in a city centre location, if you're working in a central belt, and harnessing that. We've seen some really good work in NHS Shetland. We've worked with a former role chief executive of NHS Shetland. They discovered the joy GP project, which was about allowing people to strike a different balance in their work life. After the pandemic, we're all not just chained to our desks nine to five. People want to do different and exciting things, be that within the rest of Scotland, within the rest of the UK, or even globally. Offering really flexible opportunities for people to explore new and exciting career opportunities that they may not have considered before. For me, the focus has to be about what the offer is for people who are considering remote and rural. That's very helpful. I suppose you said turning that into more of a positive in terms of opportunities that are there, rather than who often portrays a negative. The panel members online, I don't know if you want to contribute any thoughts on that. Jackie or Nicola? Jackie says to come in. Jackie? Oh, can't hear you. Got it now, that's us. Following on, I think there's something about currently the remote and rural across Scotland, but it's often at the side of other health boards, so it doesn't get priority, it doesn't get seen. The same metrics are often applied to remote and rural as they are applied to the central belt. When there needs to be the ability to look at remote and rural services in the round and look at the ability to provide a service, not related to caseload size, for example, or population size, or be disadvantaged because, as we know across Scotland, there are a lot of remote and rural areas that you've got the prediction in terms of the reduced population size. That doesn't mean that you don't still require a service, so there's that making sure that in that remote and rural there is what is required to provide the right service for families in those areas, not what is the caseload size, so we'll reduce the NRAC, allowing so we'll reduce the ability to provide that care. In terms of Don's point about housing, I know that, for example, in Skye, there were two midwives really happy to take jobs there, wanted to work in Skye, couldn't get accommodation, so couldn't work on Skye. Housing and accommodation is a huge issue, not just for workforce coming into the area, but also for students being able to afford to take up placements in remote and rural, which has a great impact on the ability to recruit. I've been a midwife working full-time in Argyllun Bute for 20 years, and the ability to bring students in and to show the amazing roles that can be undertaken in remote and rural. Often you hear this idea that being in remote and rural is a de-skilled workforce, or you risk being de-skilled. As the last gentleman said, we need to turn that around so that the skills in remote and rural are often much more broad, but also working to what would be an advanced level if there was an advanced level of practice in maternity care. I talked yesterday to midwives in the Western Isles and in Orkney, who undertake roles that are not undertaken on the mainland to be able to provide the right care. There is something about the recognition of roles of enhancing the voice around remote and rural, rather than just something that is seen on the edge of other health boards. It is really key, but also looking at services in terms of what is required for a service, not what is required in terms of case load numbers. I will comment very briefly. I agree with everything Dawn and Michael and Jackie have already said. I think that it is something about understanding what the remit of the centre will be, because what you are hearing is that this is a wider issue that goes well beyond health and social care provision. It is about housing, transport, the complexity of access to services in very remote and massive geographical areas. I think that there is also something about understanding that caring for people in remote and rural communities is challenging. There is also needs to be recognition that caring in the community is quite prevalent in remote and rural areas, and we have quite an older population there with increasingly complex needs. There is something about understanding where the investment needs to be. I would also like to ensure that the work of the new centre links with all the other work that is already going on within the Scottish Government. There are a number of centres and initiatives around workforce and addressing workforce challenges. It will also be important that it links with the ministerial task force on nursing and midwifery. Those connections are in place, and we do not end up with a number of disparate programmes that are not well connected. I want to focus on following up on that. We are running about the scope and the potential for driving innovation, either in terms of what innovative solutions are and extending to innovative ways of organising and delivering service and the role that the centre could or should have in that area. I think that if you want to see innovation in practice, you go to a remote and rural location because communities and it is not just the professionals, but communities come together and face huge challenges and overcome them. It is such a privilege to work in that environment, such a privilege to live in that space, which is why other issues such as housing, transport are so critical. The fact is that there is a wealth of innovation taking place, where we often struggle with sharing that. We can take quite a protectionist approach to practice that occurs, and we are all very different. We are all facing very similar challenges, so we need to put that aside and say whether there is innovation. Let us look and see how we can spread that innovation across the piece. I think that the next piece, which is about the multi-professional approach to this with the patient at the very centre of how we work. Fundamentally, traditional roles are rapidly changing. I am a nurse by profession, and if you think of the innovation that is taking place within nursing right now, it is light years ahead from what I trained. We have a really fortunate opportunity where we can extend our skills even further than we are currently, and work in a whole range of sectors from primary care through to urgent and emergency care. Outside the normal confines of an ambulance service, that is all innovation. It is all about shifting, working with third sector, working with community organisations, but the challenge for us as healthcare professionals is that we have to let go of some of the traditional models that we have really got used to over many, many years and embrace that and say that we will have to share some risk with the patient, and that is okay. I think that the opportunity to share learning, the opportunity to think about completely different ways of working is a really important opportunity that this approach presents. The centre needs to see that as one of its core missions, if you like, to work in that space. I think that not just the centre, but for us to be really effective, the whole of the NHS in Scotland needs to embrace that innovation, because there is often a view, and it was mentioned a few moments ago, central belt models. Unless the innovation has come from the central belt, then it is not going to be applicable, but what you find is in places like our reference Shetland again, rapid adoption of innovative models that can then be scaled back up to be demonstrated across the whole of Scotland. Rather than the other way round, you do not need big-scale models to deliver real rapid change. Anyone else want to come in on that innovation point? We do not have the benefits of big urban hospitals. I am a nurse in the background, so a lot of our nurses have taken on which is being classed as generalised skills, but it is not. They are really good skills, and they are complex skills. I worked in A&E, and then I moved to Bute, worked in A&E, worked in the ward, and in the last 10 years I worked out in the community. The amount of skills that we have to have, because we do not have those wraparound services, we stand alone. I come for the Isle of Bute. The A&E nurses are in there on their toad until a GP comes in, and they have to look after that patient on their own, so they have to have those skills. The problem is that it is seen as generalised skills, and that is wrong. The biggest issue that I hear back from members is that we have all those skills, we utilise all those skills, and I worked in Inverclyde. I pressed a bleep, and somebody would come down and do an ECG. I pressed another bleep, and somebody would do all that, but it is not recognised through pay, and that is the skills that we need out in those rural areas. The nurses are working to those levels, but they are not being recognised for it, so they leave because it is easier to go and work in an urban hospital where you get those wraparound services and you get in the banding, and yet you are not doing half the specialised work that you are doing out in the rural areas. That is good, thank you very much. I do not know if Jackie or Nicola want to come in on either of those. There seems to be a delay in the unmuting. In terms of innovation, as Michael said, remote and rural are very good at innovating, but where some of the challenges are and have been are the links to the central belt. For example, near me was introduced in remote and rural way before it was being introduced anywhere else. We were able to provide consultant appointments in the women's home, sitting beside the women, way before it was being done in the central belt and way before Covid. The challenge has often been getting the engagement from the central belt to be the other side of those links, and that is also when scanning services have been developed in remote and rural, because people do not want to travel to the central belt or are not able to travel. The most vulnerable families are the ones that are least able to travel, so they are the ones that are often denied access to care. Services are developed, but getting access to the training or the practice placements in the central belt to develop some of the skills that are required can often be a challenge. There is no lack of innovation, but there is often lack of access to what is required to make sure that those services can be developed and sustained. There is also the other issue around—I know that in many of the community maternity units across Scotland, what I hear when I go round them all is that there is no wi-fi accessible in the maternity unit, even though there are electronic records—lack of the basic infrastructure to enable that innovation to be available. The other innovation is how education is provided. The idea that you still have to go to Aberdeen, Edinburgh or Glasgow to be educated is a dated model, and we know that the ability is there to provide education so that you can earn and learn where you live because you are much more likely to stay in an area if you do not go away to train. Models so that we maintain standards require the right infrastructure and require recognition of the need for educators and academics to develop and live in remote and rural areas. It is not just about the ability to earn as you learn, but the ability to provide those career structures for people so that they remain in remote and rural areas. There is no lack of innovation, but there is often the lack of investment and the ability to take things forward. I will just briefly comment on that and pick up and say that we are looking at innovation both in terms of technology and technological advances, but also innovative clinical practice and patient care, and I think the intersection of these is really important. I agree with the points that Jackie just made there around education training, career development and looking at new models or different things. We know we have got an issue around retention with the workforce, so what do we do once we attract people? Post qualification, we are looking at nursing and midwifery, where do they go? Remote and rural areas have some particular challenges around progression opportunities. There are a number of things that can be looked at there through the task force. We know that harnessing the power of technology, we have really seen that through COVID and in remote and rural areas, that has made a massive difference to patient care and there is always more that can be done. I think there are particular issues there around funding and that is understandable, so I think that needs to be looked at through the centre. Also training and backfill, ensuring that staff feel competent and capable with the technologies that they are using. I think there is something there about the balance of care, so how do we educate our communities so that they also feel confident in the care that they are receiving remotely, whether it is digital first appointments and so on, but how does that fit the needs of what people expect from services? I also think that we need to remember we need to look beyond the NHS. We are talking about the independent health and social care sector as well and that is increasingly important because of the complexity of needs for those who are receiving social care, so I would like to make sure that we catch that within the mix. Great, thank you very much. I am a lot of doors open there that other members of the committee I am sure will want to investigate further. Thank you, convener. Just a quick supplementary on some of what Ivan McKee was asking there. Michael Dixon, you mentioned Shetland twice and innovation. What is it about Shetland that has enabled them to innovate in the way that you have described? It certainly predates my role as chief executive. A number of years ago, the various leaders of the community got together and said, and this is something that has existed in Shetland for a long time, and I apologise for the politicians in the room. Politics will always change, but we have to do the right thing for the people of Shetland. That kicking boundaries down, it does not make any difference who employs you, it does not make any difference what bad you were, you were part of the community, and that drives everything that operates and works in Shetland. It drove our approach to Covid. Check with you. Is there one health board and one health and social care partnership? One health board, one health and social care partnership and one local authority, but people have said that it must be easy then. We have exactly the same challenges. We, I am no longer in Shetland, I hasten to add. There is a fantastic team there. The team that there is faces the same challenges in terms of housing and recruitment, but it is about putting the people in the community at the forefront of the decision-making processes, and it is in stark contrast to other remote and rural locations. So, outscarers furthest away islands, very small community. We tried to recruit a nurse on a number of occasions and failed each and every time, and there was a range of reasons for that. As a nurse, you would go there and you have a tiny population. It ranges between six and fifty, depending on the weather and the month of the year. So how do we sustain someone's skills during that time? How do we get that to be an effective and attractive role? We engaged with the community and said, what is your biggest concern? How can this work best for you? The biggest concern was what happens in the event of an emergency. Who do they speak to? Scaries has a particular profile. It has no runway that can be used for flights, so it means a helicopter transfer. What we discussed was having a healthcare assistant based there. The idea of presenting this is that you see the adverts, you know, come and live on a tropical island, you and your partner, and that kind of principle that you're making a difference to a community. It's been massively successful and the community really embraced that person. Again, it's just looking at things from a different angle, stepping away from traditional, but fundamentally, the first question you ask is what do we need to do to protect our community? What do we need to do to sustain? The close working relationship doesn't require organisational change. It's fundamentally about doing the right thing for Shetland wherever you're employed by the council, by the third sector, by the NHS, and it's pivotal. Good morning to you all. Pick up on the issue of innovation. I also link it to advocacy for communities and staff, as well as the people who are receiving the care. Is there a role for the new national centre to advocate for the people in the communities? One of the submissions was from Dr Gordon Baird on behalf of Keith Ness health action team, Save Our Services Isle Sky and Galloway community hospital action group. Dr Baird wrote in that he's hoping to work with the new centre to provide information and understanding of national and regional issues and prevent ineffective repetition through feedback on effectiveness of local solutions. Throughout his submission, I think that the word advocacy is a part of that. Is that something that you would support the national centre as being part of the work? Absolutely, that's what we need. We need that voice there and that support to come out into the community, because in the remote and rural areas, just as Michael said and others have said, it's not just about the hospital settings but it's also about what's out in the community. We need people in there to be able to have that voice to help us move forward with what we need in those areas. I forgot to remind the panel that I was a clinical educator in a remote and rural area delivering what you're talking about, ECG, blood draw and things like that, so it was part of my jobs. I forgot to remind colleagues and panel about that. Thank you. I'm just a declaration of interest as a practicing NHS GP. I've heard with quite a lot of clarity about what has been said, especially what Nicola Gordon, when you spoke about the remit and what the remit of the national centre is. As is in the national centre and to understand, does the panel feel that the national centre remit will significantly address the key issues facing our workforce recruitment and retention in rural areas as it is set out right now? I think there is a risk and it goes back to Ms Harper's question a moment ago. There's a risk that we see this as the solution for everything. It will fix that. It needs to be an outcome for that. It needs to pick up this. We've got to recognise that there are many organisations involved in this that don't just have the limits at the NHS. It's also social care. It's also the links into local authority and to housing. The challenge that I mentioned previously, if you wish to come on work of the NHS in Scotland, you would need to apply 22 times to be able to work in every single board. That's an opportunity that we could easily overcome if we had a single way to be able to join the NHS in Scotland. The risk is that it becomes the solution and then to reflect on the comments that were made about from Kate Ness that it becomes yet another duplication because it's trying to do absolutely everything. I would advocate that it has to be very focused on what it aims and its opportunities that it can embrace are rather than try and be the broadest possible thing. Actually, then we'll see the delivery that it's able to do would be relatively limited. I think it's about fundamentally into tack practice to Shetland. It is about taking a clear role but knowing that it has a critical relationship with other key partners that work across the system and not trying to do everything. I believe that Jackie wants to come in on this too. Hopefully you can hear me there. Yes, I think the remit is not 100% clear at the moment but I suppose it's about having that ability to look at what's important. There is a real risk that it becomes, oh well that'll be for the centre to sort rather than ensuring and amplifying the fact that remote and rural needs to be considered within all areas that are being looked at. For example, it's being highlighted very clearly within the task force, as Nicola mentioned earlier, but there is something about having that ability to promote the fact that that anchor institution idea about having NHS and care facilities in remote and rural and it's not, and while there's innovation around substitution, there's also a risk that actually we should be promoting skills and high level of care to provide and not just the expectation if you live in remote and rural, you will make do with a lesser health service. If we want anchor institutions we need to actually look at, they have an impact on the population health, they have an impact on because you have a workforce that live and work there. I live in, I'm sitting 10 miles from the nearest shop where I live, where I've joined in and the things that make people come back and live in Argyllunbut are the fact that there are jobs, there are opportunities, you can be born here, you can live here, you can go to school here. If we keep reducing what is available then we will not have services and the population prediction will be a self-fulfilling prophecy. So I think that the centre needs to be the advocate for in all spaces. We've lost you, I think you're muted again. Yeah, so it needs to be the place that amplifies rather than the place that becomes a dumping ground for anything to do with remote and rural. And Nicola, you wanted to come in too? Thank you, thanks. Yeah, I absolutely agree with what Michael and Jack you've said. I think the problems are quite complex and long standing and they'll need some careful consideration of precisely which problems the centre is trying to solve. I think there is a risk that they could convey an impression the centre is the route to solve all the workforce and other challenges but it's a bit bigger than that so we need to narrow that down and I agree with Jack that it'll be helpful to better understand exactly what the remit of the centre will be. I think it was dawn we mentioned at the start of the session that key to all of this is workforce so we need a motivated, highly skilled, fairly paid workforce within remote and rural communities who've got access to good permanent housing, who are confident that they've got sustainable transport, good schooling options, childcare options and so on. So it is really complex and wide ranging and potentially there's a risk as Jackie has said that the centre could be seen as a little bit of a catch all or a dumping ground to solve all the issues so we need to be really careful it's not set up to fail. Thanks. Thank you so I think it's quite clear from what the panel have said that we should be finding out from the minister what exactly the remit is and then we can certainly be asking if that's appropriate to you and further panellists. One of the things that I heard being said by Michael was that it should be a badge of honour working in remote and rural areas and whilst I commend everyone who chooses to work in the NHS and especially going out to rural areas that's surely not enough do we not need to incentivise people to go out and work in remote and rural areas and really try and grab people from other areas coming into Scotland or even those in central belt to relocate so that we actually increase the people who are coming rather than try and move people that already in the area so my question is that incentivisation. Michael and then Dawn. I think there is a mixed model if you look at comparable roles across the world the Australian flying doctor services is an example where it's not incentivised in that way people choose to work because it broadens their skillset it gives them an opportunity but it also means they can take that skillset back when they finish their time they're back into the city centre location so it isn't just about financial incentives it's also about broadening your range your remit your skill base and then taking that back to your core role again it's a challenge to do that within scotland working across different organisations can be difficult and again that's something that could be made far easier just by the way we take people on the way we recruit people but also there's got to be the right people you've really got to want to work in these communities you've got to work want to work in a rural location we we certainly find that when people do go and work in a remote setting be that in an island or in you know one of the highland areas that it is either for them quite quickly or it's not and you know there is you know it's not unreasonable for people to to and as my own experience arriving into shetland in january and then going wow okay it's really dark all of the time and it's not something you'd necessarily considered you'd not factored in the fact it's incredibly expensive to heat your house if you're living in shetland because it's all electric and we're all aware of the ongoing challenges about the cost of energy you may not have thought those things through and whilst it is beautiful it isn't for everyone and I think we've got to be we've got to be pragmatic all right that's why I think it's saying it as an opportunity you can go over there you can experience it that's why the the GP joy project is is so interesting and gives people the chance to taste what it's like living in these communities and then say actually yeah I've already enjoyed this I'd actually consider a permanent role um I hope you managed to you managed to get up to shetland to do a shift because that was the last time we spoke you have something you were looking to and don if you want to come in yeah I think certainly from my perspective we need to get back to basics if we want to incentivise people to come to these areas firstly we need to have that housing there to provide it for these people secondly we need to look at the pay structures that are in place if we want to incentivise people to come in stages as my colleague Michael has said there we don't have competition like you have in Edinburgh and Glasgow we have you know small rural areas where things are more expensive to buy we also need to look at progression when you come up to the rural areas when you're working small islands you can't progress from a band five to a band six and a band seven as you can in the urban areas in Inverclydon and Glasgow and Edinburgh you you may stay at a band five for the whole of your career and that doesn't help people because they get to a point where they get fed up and they want to move away to get a better pay and move up that banding so I think looking at the band five to band six is certainly something that we need to be looking at because a lot of my members are on band fives and have been for 20 odd years and I think it's the services if we want people to come and stay in these rural areas we've got to have that service correct we've got to be able to wrap around these people mental health is a massive issue within Argyll and Bute the services are barely non-existent we're struggling constantly with mental health so it's having access to proper services if you're bringing your family there you want to make sure that you can access to services when you need them that could be you know for children paediatricians things like that and we really struggle to recruit and retain these services within NHS Highland and I believe that one of the reasons for that is we are the only model in the whole of Scotland that has a lead agency in NHS Highland and a body corporate IGIB in Argyll and Bute and that in itself brings its own complexities to people joining NHS Highland thank you thank you I'm going to move on to Enix Seaman and Ruth Maguire but can I ask the witnesses that we've got a lot of ground to cover if you can be concise with your answers please that would be really helpful Ruth Maguire thank you convener good morning everybody I'd like to ask about multidisciplinary teams and if I come to don mcdonald first and then perhaps Jackie the first questions about how teams are the role of multidisciplinary teams will be different in remote rural and island communities and I suppose specifically coming to Don if you look at Highland as an area Argyll and Bute we're talking about Isle of Bute that's closer to me in Ayrshire than it is to Inverness where your health board is and there'll be different needs within there can you speak about about the different teams and give us a flavour of that maybe yeah absolutely so we've got a lot of teams that cover the whole of Argyll and Bute and NHS Highland I think Covid was a terrible thing to happen but what it did was opened our eyes to teams so now we have those meetings where people can get access through digital to be able to have that multidisciplinary meetings around the table that we never you know that before we struggled to get because of diaries and whatever else and people having to travel because as you say Ruth it's a massive area so teams has been absolutely fantastic for that and also getting access near me as Jackie was talking about so I think digital works for us around the multidisciplinary way of working and we need that because of our geographical layout and are just to follow up on that are there challenges I mean that sort of alluded a little bit when Michael Dixon was speaking about Shetland that if you have a more compact area with your health board and your local authority and your health and social care partnership although I appreciate the space between the islands but then if we look at Highland there's more challenge there perhaps in getting the services I mean you spoke about the NHS Highland being in Inverness are we up there and then the IGBs in Argyll and Bute are there challenges around innovating between and recruiting in that way there is there absolutely is so NHS Highland does employ for all NHS workers but in Argyll and Bute you've got the IGB so although we've got NHS workers that are part of that health and social care partnership there's a bit of a complexity around that Ruth and the fact that the healthcare partnership that I'm driving makes decisions but actually we've got employees that work for NHS Highland and people get really confused about what we're and when around policies and then what do they cover so it's a massive area to cover and I think we need to be specific when we're bringing people to these areas and what the jobs can look like because we could have something for William haven't you covered Argyll and Bute? Just finally on that we speak a little bit about urban policies being implemented in remote rural and island communities but would you say that the challenge is actually almost within that hope and it's not necessarily policies from Glasgow or Edinburgh it can sometimes be policies from Inverness or Fort William being tried to be applied in? Jackie Lambert had also mentioned the issue of the remote and island areas being far removed from health boards do you want to say a little bit more about that? Yeah I mean I think as you know that we have the IGBs across Scotland but government very much talks to health boards and I mean I will talk about Highland because I spent a lot of time there but living and worked in Argyll and Bute and basically the pathways of care and the you know the consult so that when you talk about the multi-disciplinary team that multi-disciplinary team is in Glasgow and you know as Dawn said teams etc make that very possible to have those discussions and bring around but there's a real disadvantage to Argyll and Bute because they're the the north and in Highland there is much more resource and investment there and structures and Argyll and Bute sits very much often as a poor relation in that while there's a lot of amazing innovation goes on there are real challenges within that space and that disconnects sometimes between the I mean when you talk about multi-disciplinary teams in maternity services the way that they're working is with children and families and maternity working hand in hand is exemplary it's what we want around families but you know that is very invisible in many ways so there are real challenges when directives come out to health boards directly from Scottish government basically but it's very much in an integrated space like Argyll and Bute and probably like Shetland that is exactly where the daily work is going on but it can be very difficult because the policies don't always match up thank you and Jackie Lambert you mentioned there that midwives are very much part of the the multi-disciplinary teams within Argyll and Bute could you give a flavour of what that means for for patients for women who are pregnant well in terms of the multi-disciplinary team it's very much the team with children and families so it's me and and some of those challenges around we talked about parental health earlier is that some of the very short termism in terms of say for example perinatal mental health the time it takes to recruit and train somebody into our role and often the funding is around one specific person which is not a sustainable model it's almost as Don talked about a generalist model is required to upskill so that you're not dependent on one individual because that is a fragile and non-sustainable way of providing a service but often those central belt this is how we need to so for example perinatal mental health a really good example the three years funding ended before the regional roles were developed so those regional roles would have provided the infrastructure to support the remote and rural boards that would never have the capacity for the all singing all dancing services so there's often they get left behind because you will not easily and quickly recruit people to very specialist roles you have to grow your own and you have to take different approaches so the multidisciplinary team around families in Argyll and Bute is perinatal mental health it is social work it's working with that team very much and health visiting around the family and it's a good model but again it sits quite isolated in terms of how that structure is because it sits within an IGB and that can often create a bit of challenge when when you're trying to implement things that are directed through a health board. Thank you that's helpful. I wonder if I could ask other panel members as well what solutions we should be considering to address the challenges of the scarcity of specialist staff, increased home visits we've found we've heard about in previous panels as well and long travelling distances for staff members. Michael's catching my eye so. I think that the two obvious opportunities we have and as the Chief Executive's Scottish Ambulance Service you know we can deploy paramedics take on things such as home visits which releases primary care the primary care workforce the traditional primary care workforce to focus on potentially the more acute patients that are coming through the door and secondly that the use of technology it was referenced earlier on we've we've transformed very quickly during Covid to offering near me appointments some of that started to slip back and actually for patients that are in remote and rural locations that need to travel significant distances for often what is a traditional short 15 20 minute appointment that can take up a whole day if not longer if you're traveling from shetland so so letting something go with that traditional way of working is where we can make better use we would all acknowledge it's better to be in the room with a patient and often when you're delivering difficult and bad news but again working in a different way maybe using having that patient travel to the local hospital where there's somebody who can support them during that conversation but it's it's not the normal way of working of working happening anywhere so yes there are some really good examples and i would of course reference by thought me and shetland have very close working relationships with NHS grampion we've got strong patient pathways for critical care for maternity for a number of other specialities but but there is still a you know are we always thinking where people are traveling in and it isn't just an island setting you know people traveling long distance does this appointment need to happen face to face okay thank you can i bring in other panel members hi thank you can you hear me okay yes yeah great thank you i think one of the things we've heard today is about the broad range of skills that are required in remote and rural areas so speaking on behalf of that nursing provision what we hear from our members is on a single medical word the work can cover the range of services from cardiac to covid to pediatrics so the MDT model is really very much embedded just in the nature of the way that working needs to be we think there are some opportunities to look at development of the advanced nurse practitioner role so A&Ps play a key role in delivering high quality services in and out of hours in the remote and rural areas clinical decisions are taken closer to home and when patients need it and we find that increasingly A&Ps are being deployed to improve access to care in remote and rural settings we do think that things like this could be at the heart of the long term strategies that are coming through so looking at ways to sort of expand and think creatively about those MDTs and again as i've mentioned earlier ensuring that nurses have the time and are funded and supported to undergo the significant amount of training that's required to become an advanced nurse practitioner is really important some of these education and development aspects are being picked up through the task force we um if you were aware already it's got a number of components wellbeing attraction and retention education and development and culture and leadership so they're all interlinked and an element of that is a listening exercise we want to hear what nurses and midwives are telling that they want us the future specifically for their own professions but also in the MDT approach thanks thank you jackie i think wants to come too unless yeah and you were saying you were asking whether it was whether or not there already was innovation happening um there and for example the if you're a midwife working in remote and rural and you're looking after a baby that's requiring resuscitation we have neonatal teams that will be there with you in the room virtually and supporting you with providing that care and it's a model that's worked really well for quite a long time but they're streaks ahead in many ways of many others and providing that that ability um we've been doing for years of being able to be in the woman's home beside her while she attends a consultant appointment so that you have that blend of she's got somebody there with her advocate um but the that appointment could still continue so there is good you know often the issue is connectivity but when it works it works really really well picking up on nicholas point we have a real need and just talking to midwives for a recognition of that advanced practice in midwifery um and a willingness to take on things to make sure that that care that can be provided but currently it doesn't exist there and while Nicola talked about the task force and I chair the education and development subgroup my concern is we had the task force meeting last week and the the clearest message that comes across is there is no money so that is very concerning in terms of making sure that we actually get some are able to take something tangible forward okay thank you that's helpful Jackie do you have anything you wish to Jackie's absolutely right sorry Dawn yeah it's about the funding you know we can make a wish list um and in the rural areas you know Jackie was saying and in the acute ward I could be nursing a paediatric then I could be going to somebody with dementia and then I could be going to somebody with palliative and we do that we do that in a daily basis within the small rural hospitals that needs to be recognised there needs to be recognition around that because if we don't what happens is people go elsewhere and we can't retain the staff and keep them there so absolutely we need to be absolutely recognising the skills that are working out there for us in these remote rural areas so that people feel valued in the job they do thank you that's helpful thanks to you and I believe Tess White has a supplementary yes thank you convener the questions for Jackie Lambert and constituents in the northeast have shared with me that there's a huge geographical disparity in the provision of specialist services which means that many pregnant women and new mothers aren't getting the help they need um for example how could perinatal mental health services be improved as part of antinatal and postnatal care in remote and rural areas thank you thanks Tess for that question I think I touched briefly on perinatal mental health services there's a real requirement to make sure there's availability of education and development for the existing workforce but that access to regional support which again using models like near me etc are really key and that was an area that was still not fully developed from the perinatal mental health plan so there's something about we can't we will never have every specialist service in every single area and we have to be realistic within that but there are ways to have access to and so some of it's about opportunities for development but also recognition that those models maybe maybe require to be different in terms of some of those generalist roles in taking on a broader remit but there does still need to be access for the small number of times it's required for those specialist services and there needs to be ways of providing that and some of those specialist services I mean Tess you're talking about say mother and baby units in three sites in Scotland so that expertise needs to be cross board because it isn't always available in every single health board and that's still a gap thank you thanks Tess move to David Torrance thank you convener good morning to panel members around workforce recruitment and attention I know some of you have touched on the issues already Jackie could accompany you specifically what particular challenges faced by nursing and when both my staff working in remote and remote areas so the challenges can be that for example western Isles they had a student all the way through her training and then instead of taking up a post she was very much told by lecturers and colleagues that she should go and consolidate in a in a central area that person has never come back so there's a real risk in in terms of people being you know almost tropes about you have to consolidate in a in a central belt which actually isn't true there's also the the opportunities you could recruit a maternity care assistant a support worker 100 times over often into maternity and often they would have loved to be able to continue on to be become a midwife but there isn't access to that at the moment and because it's a predominantly female profession they can't leave their island or remote and rural area to go and access that education and that's something we're very much pushing for within the task forces and there needs to be access but as Dawn's also described it's opportunities for development that retain people within that I live in a remote and rural area I'm talking to you this way which has enabled me to keep to do the job I do wouldn't have been open to me previously but I also but that's also about being able to be a lecturer being able to be an educationalist and recognising that you do not have that there needs to be an infrastructure these infrastructure roles are key to actually maintaining services and they need to be recognised valued and the and a recognition that services are measured to the same standards and if something goes wrong they're measured to the same standards so that you need to be able to have that resource to make sure those standards and that development and education can continue and we need to make the most of the technology and abilities that we have to make that possible thank you that Jackie my next question my co I've done conscious of time so um what are the additional challenges for ambulance and urgent care staff working in areas where long distances been doing services are in norm so what you're talking about is normal business for Scottish ambulance service you know the the the crews and I've been fortunate enough to spend a lot of time in the crews during my first six months as chief executive and they love the job they they acknowledge that driving on distances or travelling in helicopters planes is is normal for the role that that comes with it um the the biggest challenge that we have is uh that the routes we used to use for recruiting technicians to move into a paramedic role so you'd have an opportunity to to be able to step up through the workforce gain promotion gain greater skills that all now runs through university so we don't have a currently earn as you learn programme for technicians who aspire to become paramedics um and actually there's a kind of conveyor belt we have uh call handlers who do really a really difficult job taking those 999 calls dispatching ambulances who may aspire to become technicians we can do the technician training but they aspire to become paramedics so we're working very closely with scolch who want to get that tech to paramedic group re-established at the minute the primary pressure is hospital hand over times but i'm probably suggesting we don't go to that discussion during this session today um but the the main thing is they genuinely love the job and actually for local paramedics they have a skill set which means they can leave people at home they can and often do work really innovatively they speak to consultants they speak through to the emergency department to try and keep where possible people at home rather than convey them to hospital i think nicola gordon wants to come in briefly on your previous question thanks thanks very much can you hear me okay yes yeah great thank you yeah just just coming back to that that question which was a good question around recruitment and retention and picking up on some of the points that have already been made we are hearing from members that the additional responsibility in remote rural roles is not necessarily or always recognised within the pay structures so what we can find is within the nhs a band five nurse can sometimes be the only registered nurse on shift and she's doing that at a band five pay level but taking on the responsibilities that you would normally have from more senior nurses so covering the role that might be covered by a senior charge nurse or a band seven nurse so the pay structure doesn't reward that and that that can be a disincentive um you also know that our members in remote and rural areas love the work and it's where they want to be but there's something there about finding a solution so that those career opportunities are there and there's perhaps a different model that that recognizes the breadth of skills that are applied all the time I think as well um that question around um you know attracting and retaining people and I think this has also come up today is that what our members tell us is that the perception of what work in life is like in a small island community and in this case this example I'm thinking of Osherland is it's different to the reality nursing in rural areas isn't isn't quiet and slow paced it's just as stressful and hectic as elsewhere and it can be more so it's very busy um so there's something there around making sure that people are aware what those opportunities are what it's like to live and work in a remote and rural community but picking up what Michael said earlier but absolutely attracting people and saying this is an excellent way of living it's an unusual and that's a rewarding and it's a way of life that people absolutely love um but how do you get that balance right and how do we provide opportunities for newly qualified nurses and make sure that the student placements are providing those opportunities as well thanks Paul Sweeney thank you convener and good morning to the panel I attended around table with student nurses a few months ago and a number said that whilst they were keen to take up placements in remote and rural boards they were simply not able to do so as they were not able to secure accommodation and it was often too costly for them to move is that something that rings true with the panel um and how do we give students and qualified practitioners in a number of different disciplines the tools to fulfil positions that they might want to take up in remote boards perhaps I could start um with Jackie Lambert thanks paul um you're absolutely right about the challenge again it's come back to a challenge about accommodation um and I've seen innovation I mean in Argyll and Bute we don't have any vacancies for midwives because we've offered opportunities you know we've been very innovative in offering we I'll say past tense and providing opportunities for development and opportunities and also for students to be employed straight into remote and rural there was often a misconception that you couldn't go and work in remote and rural unless you'd consolidated for a couple of years in the central bell area we've we've proven that that's not the case but accommodation is consistently a challenge both for them when they're undertaking their student experience and placements but and you know and we've we've you know we've worked with local caravan sites and everything to try and get around some of these challenges but for taking up posts it's it's a challenge when people already have um you know more experience and more are learning more but it's a real challenge at the beginning and you know and we don't have priority housing we don't have any way that actually so if you look at incentivising being able to get a home in the area one makes you start feeling like you belong but also opens the door to be able to recruit into these areas it's the biggest challenge we have perhaps mr dixon do you have a similar position in terms of paramedics so paramedics it's slightly different but it is comparable wherever you wherever you look in a remote and rural setting accommodation is a primary challenge would recognise absolutely the key worker issue so if we want people to live and work and stay into that local area being able to find a house that they can buy actually supplies is critical i do need to flag that there's also the hmrc component so if people are doing rotational work away from the central belt and they're going to do a three or six month placement in a remote and rural location their housing is considered a benefit in kind i find that quite frankly bizarre that they would receive a tax bill for trying to help the people of Scotland but that's genuine in the case for our junior doctors who come and have a placement into the health board so it's it's a multifaceted problem but absolutely spot on thanks and Nicola Gordon do you have a perspective on this yeah thank you yes i mean in terms of the nursing student perspective this is a particular challenge you'll be aware that us here in Scotland surveyed students early this year we had a really high response rate and we held a round table on that we published our report nursing student finance the true cost of becoming a nurse we found that nursing students across scotland are facing significant financial pressures it's partly linked to cost of living crisis obviously but we found that 66 percent or two-thirds had considered dropping out of their courses because of financial concerns and 57 percent of those it was due to the cost of placements so getting placements the accommodation transport it can be a particular challenge for remote and rural areas because the distance is involved and we do find sometimes there's quite late notice so some students are telling us they get about a week or so notice that they need to go into one of the islands for their placement so then it's a bit of a scramble obviously to get travel and accommodations sorted and we also know that yes some of the students have actually pulled out of clinical placements because they aren't able to get accommodation so I'd say of those challenges accommodation is the one that's probably the most critical to try and do something about let's come up a number of times today and there's also things around clinical placement expenses but we're making progress with Scottish Government to look at that which is positive thanks. Donald Macdonald, do your members feedback similar pressures in terms of remote and rural placements? Yeah absolutely when I worked in the community we had student nurses coming down and they ended up giving up their placements because they couldn't pay the accommodation or they couldn't get accommodation housing is a massive issue within the remote and rural areas but actually see where we do supply those houses what we're getting feedback from students are the rich knowledge and experience that they're getting in these areas that they wouldn't necessarily get in Glasgow or in Edinburgh in places like that they are seeing a whole different skillset out there and they really value that. You mentioned where that is provided, is there particular examples where that's quite a good model that we could look at relative to other areas? Well I suppose what we did in Bute to keep the student nurses coming there because we're a small island sitting in a thousand population and we wanted to keep the students coming as we spoke with some of the hoteliers so in the winter they're quiet so we did a deal with the hoteliers that would bring the students in and give us a reasonable price for them staying there. I can't say the accommodation was always fantastic but actually I want to reiterate that when that did happen they said that the absolute experience that they got was absolutely invaluable. That's great. Do any other panellists have a view on pockets of good practice out there that we could hone in on? Has anyone got any suggestions for us to look at in terms of accommodation provision particularly or any particular practice in terms of promoting student placements that work really well? Do you want to come in here? Yeah, thanks. Again what we've seen is actually protected accommodation so when there still is nurses residences actually protecting and keeping us space it's always available for students that's worked in some areas and some of it has been to the point that sounds ridiculous but members of staff actually renting you know having rooms that they make available I've seen that happen which is maybe going a bit above and beyond but part of it is the challenge of getting those arrangements with local B&Bs local you know so that you know that those arrangements are in place it is seasonal though and that can often be the challenge but what I know in some of the hospitals that they do is that they put adverts to see if people would you know if their folk are available to make rooms available and things so there has been some real innovation because people want these students they want folk to come in and work in the area but often it is about having local arrangements in place or protecting space often the challenge was that space was protected for medical but not for nursing or midwifery and you had to really fight a corridor for nursing and midwifery. Okay thanks very much if there are any thoughts that spring to mind of places to look at do let us know by correspondence that would be great thank you. Thank you, Gillian Mackay. Thanks convener and good morning to the panel to what extent is the right data available to ensure that the right services and staff are in the right places and that we're adapting those staff to reflect the change in demographics particularly with the ageing population that we have and the increased number of people who are retiring to remote and rural locations. Dawn is nodding so I'm going to pick on you. I don't think the data is I think there is data I don't know how good that data is and I think that becomes an issue so how do we provide that and I think we need to look at how we do provide that because geographically we know that the people come to our areas to retire so we have got a lot of elderly people staying in that area and the problem we have with that is that a lot of the younger community who we actually want to rely on for care at home we can't recruit to so I think yeah absolutely that I don't know how we do that and I don't profess to be but actually you're absolutely right we need to be able to enhance and gather that data so that we can look at that and be able to reflect and act on that. Don't anyone else want to come in at all? Hi I think some of the challenges with the data is that things like SIMD quintile do not particularly reflect well the populations that you have in remote and rural because as we know it's easier in the central belt to be able to define the SIMD quintile but within remote and rural that poverty sits right next door to somebody that is well off so some of that data under reflection of the demographics is challenging and also while we know there are definitely a lot of retirees a lot of people coming into an area etc it's I keep coming back to this you still require to provide services if not yourself fulfilling prophecy and people will not stay young people will not stay in an area because there isn't opportunities for development and opportunities for schooling and for maternity maternity services etc so there is a bit about how do we prevent what is what is happening and how do we go upstream rather than just watching something happen hi thank you yeah so have you had asked the others that the data used to inform workforce planning needs to improve we know there's significant gaps in the data that needs to be addressed that can be a particular challenge for social care and general practice nursing we would find it helpful to have an accurate and transparent workforce baseline data set published ahead of the implementation of the health and care staffing act in April next year so the improvement can be measured based on that and as part of the annual reporting we'd also like to see workforce planning undertaken alongside and integrated with service planning that service planning needs to be based on population need rather than financial considerations and constraints and the commitment to creation and sustaining a skilled staff mix reflecting the needs of the community all of this needs to be based on really robust data so we do this see there's some challenges around that and in terms of the challenges facing on rural areas the planning budgeting designing services they're all they're all really linked so having that that data set to underpin it is so important i suppose our view is then looking at where there are the gaps and what can be done to address that as a key thing we'd want to see focused on thanks i'll keep it brief i actually think we have a vast amount of data in hs scotland it's astonishing what we don't necessarily do is translate that into really meaningful information so good decisions are making i think just to put in context whatever we have right now it will take at least three years to adjust so you know that that is the training time it takes to get a competent to a practitioner to start their competency-based learning in terms of moving forward i think what we do know is that we do have profound challenges in terms of nursing in terms of medicine i will speak for scotland service where we can continue to recoup paramedics without any significant difficulty in fact we could expand the paramedic workforce and that would particularly if they were used judiciously across the whole of the entrance in scotland really helped to augment where we fundamentally do not have the supply coming in and of course the other factor is the universities and looking at the attrition rates and that is variable across universities in scotland i think that's something that we as an organisation really need to hone down on in the entrance of time i'm going to do a really quite fire question here that i hope everybody will forgive me for putting them on the spot we've spoken already about about housing about people often acting up a band or two in some cases what would your one ask of workforce planning one key thing to take on board in times of workforce planning going forward that you think would really help within your own within your own disciplines within the remote and rural area pay absolutely i would say let's look at supply jack here nicola yeah just to say sustainable long-term funding yeah it's about workforce planning that reflects as nicola said population need and service provision not case load size and and again that sustainability in terms of career options and progression that's great thanks thank you thank you Ruth Maguire all right convener i think i covered my questions did you have me coming back in that's absolutely fine thank you um i'll move to iven mickey thanks very much um we've talked about innovation i wanted to focus just very briefly on technology digital technology and other technologies and get a sense of where you think the role of the centre should focus there what the barriers are to bringing in new technologies and what support is needed to ensure their successful implementation and rollout so i don't know michael do you want to go first on that uh yeah from from personally the first question is from the centre's perspective fundamentally we still have independent health boards that that are accountable to the local communities about delivery of service and so again i personally feel that the centre has a role in bringing those together particularly when we see workforce moving across as they do across organisational boundaries demonstrating where good practice is and showing the opportunity of where that can be deployed effectively rather than necessarily taking a leading role because i worry then we start to duplicate other roles and responsibilities that currently exist i think digital is transformational if used effectively the the duplication the amount of times and we we say this the work that we're doing between scott shambles service and hs 24 about stopping the patient needing to repeat their story to yet another person to yet another person not even taking aside that the the distress that causes for the individual the amount of time that we waste for practitioners but but also practitioners need to learn to trust the information that's being gathered by another healthcare practitioner so i think the potential is there i think we are on a really strong foundation with a single kind number across hs scotland which is massively powerful but i think we're only at the beginning of what that potential could look like okay thank you um anyone else want to comment on that jackie does that yeah technologies essential um for taking forward services but also so the education development training to support it it's not just about the hardware it's making sure that um so that you get the best quality um of care and and that people feel confident both the people you know attending for care but also the people providing care so that there's clear standards of what to be expected and people have the right training and development and time for that to be able to make the best use of that technology great don yeah suppose there's a couple of things certainly for us um we have we struggle with technology when it comes to our catering in our hotel services they don't always get access to computers um we're moving everything digital and i think that's an absolute shocker when you've got people who can't access a pay they can't access to go on to do their annual leave because they can't get access to a computer and i think in this day and age if we are going to move digitally we need to think about these people we need to put in that training that's there but i think the bigger issue for me being from from a nurse's point of view is care plans we're still doing written care plans in people's houses and i'm not saying there's anything wrong with that but we had mydys and had to get it taken away because it was costing too much but actually people could social work could get in mydys and see what we had done each piece could get in doctors could get in you know so everybody could get absolute access and wrap around that patient centre care but it had to be taken away because it was too expensive so we're going to talk about digital then we need to make sure that we're going to find it it was taken away because it was too expensive whose decision was that locality managers right okay that's very interesting okay adona nicola did you want to come in on this this issue thanks yeah just um just a brief point i think i think michael made a really interesting point there about trust and organisational boundaries and i think it's something here about remembering that digital solutions underpin services that are delivered by people so ultimately health and social care is about people providing services to other people so i think we need to remember that they're at both ends of the spectrum and the digital is the is an enabler for that to happen and something that's maybe something worth bearing in mind and i'm conscious that through the proposals for the national care service there was discussions around a single national health and social care record and so i don't know at what stage that the work has been done and much of that's been done through co-design so i don't know the extent to which that has progressed or has been looked at to ultimately have some and that is accessible right across the spectrum of health and social care services but obviously it's it's on the radar for Scottish Government and presumably as those plans develop we'll hear more about that as the bill progresses through stages thanks indeed thank you very much thank you to the panel have any examples of where digital interventions have worked well to improve access to healthcare either in remote areas or in any boards across scotland that could be captured and scaled up to become a national standard just if anyone has any immediate insights thank you so i apologize i keep talking about show this is a really amazing place so the lead consultant for diabetes worked closely to hold a portfolio of patients particularly those that may be either serating or considering going on to the the pumps that monitor the patients blood sugar levels and so rather than saying that there's a divide between acute and primary care which is an artificial divide anyway what they did is they created a team's channel so they could review patients with the gp surgery with the the community and district nurses to make sure that the patients were continually monitored it meant that the patients didn't need to go to the all the way and that do mean all the way to the gilbert bain hospital that there could be a local review that the gp could work closely with the acute consultant to make sure if there's any deterioration it could be picked up early and adjusted and it's and it's using that digital analogy it didn't need the patients necessarily to make that journey it was about changing the way of working to try and empower the community teams that work with them more regularly but to not lose sight as there is also an expert that can provide them with help and support and reach back that way is there any other examples that any panellist would like to mention Jackie? I think just one that we've mentioned already because things like near me meant that and we counted the miles that was you know that the carbon footprint that was saved and it was calculated because the people were not having to travel two and a half three hours down to Glasgow to see a consultant the same for scanning services being provided locally but with remote oversight of looking at those scans you know and also the the way that the neonatal teams would be actually another pair of eyes when you were caring for an ill baby where they were monitoring the they can move the cameras they can look at the baby so that you can have your hands on and care for that baby these things are happening now and they work really effectively but again it's about resource and a recognition that these require skills and training and you know the infrastructure to support it so much of it is about getting the central built to buy in the willingness for innovation is there in remote and rural areas and often the ideas to turn to the central built speaking to gps in Glasgow they were highlighting that even if there are opportunities for technological improvement they simply don't have the headspace to even think about how you would implement or deploy such technologies is that a similar constraint that you feel that the people the staff you represent have that they simply there might be a capability out there but they're so focused on the immediate clinical demands of provision that they aren't able to necessarily think about how to deploy that or do service improvement what could be done to try and create that space to deploy new technologies i think it's particularly challenging it's often easy just to kind of keep your head down and going with what you've done before because actually change will mean stopping what you're currently doing switching to a new system it's exhausting it's time consuming and as you rightly said the belief is i just don't have the time to be able to do it so the use of targeted project management resource as we did in Shetland as we have in Scottish ambulance service can be really useful to come in and and and help people just lift their heads up for a moment if the way people are no one goes no one goes to work to do a bad job and and if you've always done it that way then why would you consider stopping and changing to something else so helping them through that change process project management support can really help them in terms of okay i can see what's possible i can see how i'm able to stop doing what i'm currently doing let some stuff go and actually focus on new and innovative ways certainly from listening to our members is we're struggling to give basic care in the hospitals at the moment because of recruitment and retention so to you know and that's most important for us it's a bed site we need to be there with the patients um so when we're struggling with the recruitment and retention of staff you'll you'll know that the words are short we can't get the staff to come in we're using a lot of agency then to try and you know say to those staff who are nearly burnt out hear something different they just can't they can't get their heads into that space because they're too busy looking at the bed sites and looking after the patients a bit of a vicious cycle you would say yes okay i just also wanted to pick up on the point that's been raised repeatedly about broadband being a physical constraint to accessing a lot of critical you know services and capabilities do you feel the NHS should do more to for example if there isn't a fixed line broadband connection into certain geographies provide satellite broadband services to all staff so there is that assurance that they can have access to the the basic infrastructure required to put up perhaps you know do consultations or access key services is that the sort of thing that might be worth considering or looking at perhaps of his perspective on that mr Dixon we've found it again talk about shutlands you're not going to be out the NHS can't be the solution to literally everything so you know we rely on mobile technology as well as broadband fixed link technology where we worked very closely with a particular community who was working through their community hub so helping them establish a suitable space where a consultation could take place in a clinical in a community hub rather than again expecting the patient to travel all the way down to the mainland hospital in Lerwick and i think it's it's again the risk is we we try and see that solution for everything the hopefully with expansion of the rural mobile networks the sharing that should take place that should give us greater opportunities but but at its heart and to reference the national care service a single patient record that we've got a long way to go before we end up in that space and mobile technology is great but it has to work in a way that's both offline and online and then reconnect and roll the records up okay thanks i think both Jackie and Nicole want to come in oh Jackie would you like to come in yeah and i think um while we can't relax you know i agree that the NHS isn't the answer to everything but to move into an electronic way of working um where every maternity record in Scotland is digital but the mid-wise of real challenges because there's no wi-fi so it's not just about the broadband connection though it's about having the in small areas you have very few people working in the NHS to actually do the it you know so they are in very short supply so there's also that sort of like infrastructure to support that it infrastructure being developed because you can't have it with the electronic records no paper option those electronic records are amazing it means that the obstetrician in Glasgow can be looking at the same record as somebody on isle is looking at but you absolutely need to be able to connect so that you can from offline to online etc and it's a real challenge and it creates risk if we don't have that infrastructure so we can't move electronic we can't get it right without the proper training and the proper infrastructure we saw it during Covid and the public health Scotland undertook a large survey of both people receiving care and providing care in maternity care during Covid and the biggest issue was about training and development so being expected to move to new technology without the appropriate infrastructure and training to do that which then often puts people off taking forward something that actually can be great so you need that project management you need that rollout of something in a way that's supported so they can do remote monitoring which works really well. Thanks for that. Nicola Gordon would you want to come in on this point as well? To agree with what Jackie's just said there and pick up that the immediacy of the current workforce challenges do make it really difficult to be able to free up people's time to undertake the training that they need so yes the infrastructure and broadband connectivity is important but it's really about people being able to use those systems as well and we know that on the NHS alone we've got around five and a half thousand nursing and midwifery vacancies so the pressure is very much on providing frontline services so the scope and the capacity to free up time for a number of the things we've discussed today really isn't there at present so it's about dealing with those workforce challenges at the same time as trying to bring in some of these other solutions that would complement that. Thanks. Thanks very much I appreciate it. Thank you. My questions for Michael, Dixon and Michael just to highlight one profound challenge we face right now giving you an example over the weekend as many as 17 ambulances were stationed outside Aberdeen Royal infirmaries A&E department and that serves as we as you know rural both rural Grampian as well as urban areas so my question is do you anticipate this will get worse over Christmas and new year and what are your thoughts for actions to ease the pressure on Scottish ambulance service both now and in the future? Thank you I'm profoundly concerned about the the pictures and obviously I'm aware of the the challenges that have occurred in both Aberdeen Royal infirmary and Dr Gray's so I don't think anyone is trying to belittle the the situation I think it is a profound challenge our bigger concern is that Aberdeenshire is a if you like a single location there's no ability to be able to call across as you will do between Glasgow and Edinburgh so my concern is also about the rural communities that surrounds Aberdeen the wider Aberdeenshire fundamentally we're working really closely with NHS Grampian in terms of looking at how we can increase the number of call before you convey so this is about trying to stop people needing to be transported to either AI or Dr Gray's to try and help people reach alternative models of care and we have an excellent integrated clinical hub and a flow navigation centre so we can try and get people to different locations however fundamentally and this is a massive point of frustration for for the crews that are caring for patients in the back of ambulances they want to be out on the roads references earlier they want to be you know picking up patients who are in in dire need of help and care and they're unable to do that because they're parked for for often hours outside an accident emergency department providing the best care and I've been out with them I've spent hours in the back of an ambulance caring for patients and I've seen the exemplary care that they provide but fundamentally we are even with additional support of the hospital the asian officer who is our member of staff working closely with the accident emergency we are dependent on that flow through I think we've got to recognise that there still exists a profound number of delayed discharges across the whole of the NHS in scotland we have to recognise that that 1800 patients are currently sat in what is considered the wrong beds for their care needs but the fact is it's about the flow through the system and we're working all I can say is we're working incredibly closely I don't think it's going to suddenly miraculously transform and we won't have any weights we expect that there will always be demands on our service so there will be delays and we see that across scotland but the profound challenge we're seeing NHS is our significant concern to myself and to the rest of the board and each and every single crew member who's working really hard across the Aberdeenshire area thank you just a quick question about outside of current issues does the scotland service have enough capacity to deal with remote and rural it's not just emergency transfers there's also patient transfer to appointments as well so is there something I mean what would you respond to that is there enough capacity so over the past three years we've significantly increased our ability to be able to respond through a programme called demand and capacity and I'm happy to share some information about how that's increased the number of paramedics and texts that we have across the whole of scotland we've that's rebased in a number of particularly remote and rural areas our provision to make sure we've got more extended provision in some centres moving it from what's previously 12 hours into 24 hours I think we're faced with two challenges one is that we could continue to expand the scotland service and all we do is create more vehicles that will end up being parked outside the front of an accident emergency right now we need to shift that from a system point of view we need to see a greater focus on the back door and the flow through our acute hospitals to enable that transfer we did that demand capacity modelling on a a much shorter hospital turnaround time so the benefit we're realising what's significant and that expansion has been huge has been limited simply because a hospital hand over times has been greater than we models significantly greater in a number of areas so I think we're in a much better place than we were previously however the big focus has to be about making sure that we help patients get to the right place the principle of no wrong door be that through NHS 20 through all be that through the 999 system and people often do dial the wrong number and that's not their fault it's a stressful situation if your relative is unwell so we need to help them to get to the right place using flow navigation centres our integrated clinical hub even down to yesterday I was up in Inverness seeing the mental health sorry we've already ran overtime I'm going to move to Ruth Maguire for a final theme thank you convener and forgive my mind blank earlier I did have another question I want to ask about palli tiff care and I suppose this will probably be for Don MacDonald and Nicola Gordon just to ask what planning is happening or should be happening around that changing demographic in our in our rural areas we spoke earlier about how communities were older and I've previously asked witnesses about the choice for individuals in terms of where they will be and be cared for do you have any thoughts on that yeah absolutely so for me we struggle with Marie Curie in the remote rural areas so we provided the palli tiff care um we did a pilot to look at bringing community nurses on to night shift because we don't want anybody if people want to be at home and they want to die at home absolutely that's their choice and we should be able to provide that but we shouldn't believe them at night and they're dying through the night with nobody with them that's just for me unethical we shouldn't be doing that so we piloted that and I think it was a good pilot but it was stopped because of finances so I think what we need to do is we need to look at if we are saying to people you you have a choice to die at home or you have a choice to die in the hospital then we need the resources and the tools to enable that to happen with dignity and respect yeah I'm a layer of time but um you spoke about a pilot there there seems to be a bit of a theme in terms of pilots or projects which actually should be about core services but they're they're treated as an extra how do we get round that what's the we need to stop the language that shows this test of change it's not a test of change what we need to do is we need to get around the table and absolutely as my colleagues said we need to get an understanding of what our communities need what are the services they require but more importantly we need the funding for that so we can consultate and we can speak with all our community and we can promise you know this is what you's all want but if we don't have the funding from the government to provide that and the resources then there's there is no point to that thank you would um Nicola Gordon like to come in on that pallid of Gorgasio Gorgasio yeah hi Ruth just just very briefly I'm also conscious of time I think one of the things that we've touched on during today's session is about the the breadth of skills that that nurses you know demonstrate daily in terms of their roles so we've asked speaking with a member recently in one of the examples that she was giving was actually around neurological deterioration that was a good example of the you know providing that pallid of an end of life care along with providing the range of other services but one of the observations she picked up was the need for post qualification education and training for nurses in remote and rural settings who are expected to provide that breadth of care and and she said that neuro deterioration is is really important because it can be very small changes so I think that's something we'd like to look at we're um we're aware that obviously the this of it you know will be introduced in the spring around assisted dying and within that wider conversation about pallid of an end of life care that is something that we are starting to look at within RC and so we'll be picking up some more work on this next year and that's something that we would obviously have more to say on in future but it's something that we we're really interested in looking more closely at. Thank you. Emma Harper. Thanks conveners a quick question for Jackie about remote and rural midwifery practice. NHS Denfrews of Galloway stopped allowing babies to be delivered at Galloway community hospital in 2018 so now women have to go 72 miles and babies are being born at the side of the road so that might be even at something for Michael to pick up. I know there's challenges around education competency skills recruitment and safety obviously it's a huge issue so I'd be interested to hear from Jackie just the comments about about the necessary requirements for skills development and safety when it comes to delivering babies. If you're working in remote and rural areas and I know where you're talking about it's about recognising the skills that are required and also remunerating and offering that development so that you are very isolated in your practice it's wonderful to work in remote and rural practice because you do use all your skills but there is no recognition of that so if you're trying to create a model without any consultant advice any advanced practice expecting everybody to do the same job and to be on call at a much higher level than many people would find acceptable you're going to have a challenge recruiting to it so it's absolutely right that people should be able to be born in communities but it's absolutely right that people should be paid appropriately their roles recognised and have enough of a workforce so you're not putting a burden of on call that is not sustainable on a predominantly female workforce with children families etc that they end up leaving the services or going into other jobs like health visits or family nurse partnership because they cannot sustain being able to provide it so I do worry about the discussion around babies born at the roadside because mothers are transferred across Scotland and from all different areas and I'm really concerned that we don't introduce fear into the fact that we have wonderful ambulance services and we have wonderful services that make it very safe for people to be transferred because it's not suitable for all women to give birth in remote and rural areas so I'm always very concerned about the narrative because what I don't want is that for any woman to feel scared when she is requiring to be transferred with her appropriate care. Panels may be familiar with the work of Glasgow University and Marie Curie doing a project called dying in the margins which highlighted the reality of people who are terminally dying at home and particularly in poverty with poor adaptions to the housing situation. What is your own experience of how end-of-life needs and wishes are addressed in rural settings and are there particular challenges in supporting people to have the death that they want that we may not see as much in urban areas because they don't have that autonomy of decision making about staying at home in the final stages of their life? Has anyone got a particular view? Absolutely, if somebody has stated to us that they want to die at home we will do everything we can do to make that happen so we've got the green cross that goes outside the doors of the ambulance know that this person wants to not be resourced they've got all their stuff in there and whatever else but actually it's about that caring service so it's not just about the NHS it's about social care as well because they need people there because we don't have Marie Curie or we can't get Marie Curie so it's how do we support that in the community for somebody to be there as I said to Ruth nobody wants anybody to die on their own but how do we fund that how do we train people up and how can we take the social the care services we've got in the community to support that? Is there any other perspectives on that? Just as I said Scottish Embassy Service have a partnership with Macmillan in terms of supporting people to die in the location that they prefer to I'll happily share some information afterwards if that will be useful about that work Okay how do you feel that potentially social housing providers are they co-operative in terms of making adaptions to people's houses is that something you have experience of about how people's homes and rural settings can be made and adapted to support people to stay home rather than going to a hospice or acute hospital? So in rural communities the OTs will come in do assessments, physio will come in and do assessments and work in multidisciplinary ways and it seems to be that housing are you know happy to do that to help you know people to stay within their homes and adapt the areas like bathrooms or whatever that are required for those people to stay home? That's helpful thank you I think this is where issues go wider because I know that you know where I live it's very very difficult to provide that level of care because people could be living five miles up a glen they can be and there's something about that again going to that wider social determinants and looking at when community hospitals are built that there actually needs to be a sheltered housing and housing built around so that actually the limited care provision we have can access people so that they're moving into housing sometimes nearer for facilities that are available provided when they choose to rather than at a time when they are in distress and part of the challenge is that we have a you know a limited workforce in the community and you know huge huge distances and some of that town planning perspective which is not for us to solve would make a big difference in the long term would be able to provide that care at home. Thanks very much thank you for that I appreciate it. Thank you again can I thank the witnesses for their attendance today at our meeting next week we'll be continuing our inquiry into healthcare in remote and rural areas with a further panel of witnesses as well as taking evidence from the chief executive of the Scottish Football Association and that concludes the public part of our meeting today.